Intermittent vs Continuous Pulse Oximetry in Hospitalized Infants With Stabilized Bronchiolitis: A Randomized Clinical Trial

Abstract

Importance: There is low level of evidence and substantial practice variation regarding the use of intermittent or continuous monitoring in infants hospitalized with bronchiolitis.

Objective: To compare the effect of intermittent vs continuous pulse oximetry on clinical outcomes.

Design, setting, and participants: This multicenter, pragmatic randomized clinical trial included infants 4 weeks to 24 months of age who were hospitalized with bronchiolitis from November 1, 2016, to May 31, 2019, with or without supplemental oxygen after stabilization at community and children's hospitals in Ontario, Canada.

Interventions: Intermittent (every 4 hours, n = 114) or continuous (n = 115) pulse oximetry, using an oxygen saturation target of 90% or higher.

Main outcomes and measures: The primary outcome was length of hospital stay from randomization to discharge. Secondary outcomes included length of stay from inpatient unit admission to discharge and outcomes measured from randomization: medical interventions, safety (intensive care unit transfer and revisits), parent anxiety and workdays missed, and nursing satisfaction.

Results: Among 229 infants enrolled (median [IQR] age, 4.0 [2.2-8.5] months; 136 [59.4%] male; 101 [44.1%] from community hospital sites), the median length of hospital stay from randomization to discharge was 27.6 hours (interquartile range [IQR], 18.8-49.6 hours) in the intermittent group and 25.4 hours (IQR, 18.3-47.6 hours) in the continuous group (difference of medians, 2.2 hours; 95% CI, -1.9 to 6.3 hours; P = .17). No significant differences were observed between the intermittent and continuous groups in the median length of stay from inpatient unit admission to discharge: 49.1 (IQR, 37.2-87.0) hours vs 46.0 (IQR, 32.5-73.8) hours (P = .13) or in frequencies or durations of hospital interventions, such as oxygen supplementation initiation: 4 of 114 (3.5%) vs. 9 of 115 (7.8%) (P = .16) and median duration of oxygen supplementation: 20.6 (IQR, 7.6-46.1) hours vs. 21.4 (11.6-52.9) hours (P = .66). Similarly, there were no significant differences in frequencies of intensive care unit transfer: 1 of 114 (0.9%) vs 2 of 115 (2.7%) (P = .76); readmission to hospital: 3 of 114 (2.6%) in the intermittent group vs 4 of 115 (3.5%) in the continuous group (P > .99); parent anxiety: mean (SD) parent anxiety score, 2.9 (0.9) in the intermittent group vs 2.8 (0.9) in the continuous group (P = .40); or parent workdays missed: median workdays missed, 1.5 (IQR, 0.5-3.0) vs 1.5 (IQR, 0.5-2.5) (P = .36). Mean (SD) nursing satisfaction with monitoring was significantly greater in the intermittent group: 8.6 (1.7) vs 7.1 (2.8) of 10 workdays; the mean difference was 1.5 (95% CI, 0.9-2.2; P < .001).

Conclusions and relevance: In this randomized clinical trial, among infants hospitalized with stabilized bronchiolitis with and without hypoxia and managed using an oxygen saturation target of 90% or higher, clinical outcomes, including length of hospital stay and safety, were similar with intermittent vs continuous pulse oximetry. Nursing satisfaction was greater with intermittent monitoring. Given that other important clinical practice considerations favor less intense monitoring, these findings support the standard use of intermittent pulse oximetry in stable infants hospitalized with bronchiolitis.

Trial registration: ClinicalTrials.gov Identifier: NCT02947204.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Mahant reported receiving grants from the Canadian Institutes of Health Research (CIHR) during the conduct of the study and grants from the CIHR and personal fees from the Journal of Hospital Medicine outside the submitted work. Dr Wahi reported receiving grants from the CIHR during the conduct of the study and grants from the CIHR and the Hamilton Health Sciences Foundation outside the submitted work. Dr Bayliss reported receiving grants from the CIHR during the conduct of the study. Dr Kozlowski reported receiving grants from the CIHR during the conduct of the study. Dr Breen-Reid reported receiving grants from the CIHR during the conduct of the study. Dr Moretti reported receiving grants from the CIHR during the conduct of the study. Dr Schuh reported receiving grants from the CIHR during the conduct of the study. Dr Parkin reported receiving grants from the CIHR during the conduct of the study, grants from the CIHR and Hospital for Sick Children Foundation and nonfinancial support from Mead Johnson Nutrition outside the submitted work, and peer-reviewed grants for completed investigator-initiated studies from Danone Institute of Canada (2002-2004 and 2006-2009) and the Dairy Farmers of Ontario (2008-2010). No other disclosures were reported.

Figures

Figure 1.. Flow of Participants in the Trial

Reasons for meeting exclusion criteria and reasons for not being approached for consent are not mutually exclusive. A total of 101 of 229 infants (44.1%) were recruited from community hospital sites. See the trial protocol in Supplement 1 for further details. PICU indicates pediatric intensive care unit.

Figure 2.. Kaplan-Meier Plot of the Proportion of Infants With Bronchiolitis in Hospital

Cox proportional hazards regression of the primary outcome of length of stay from randomization to discharge, stratified by site and adjusted for sex, resulted in a hazard ratio of 0.93 (95% CI, 0.71-1.23; P = .62).